Oncoplastic breast surgery for the management of ductal carcinoma in situ (DCIS): is it oncologically safe? A retrospective cohort analysis

Ductal Carcinoma In Situ (DCIS) and Microinvasive DCIS: Role of Surgery in Early Diagnosis of Breast Cancer

Advances in treatments, screening, and awareness have led to continually decreasing breast cancer-related mortality rates in the past decades. This achievement is coupled with early breast cancer diagnosis. Ductal carcinoma in situ (DCIS) and microinvasive breast cancer have increasingly been diagnosed in the context of mammographic screening. Clinical management of DCIS is heterogenous, and the clinical significance of microinvasion in DCIS remains elusive, although microinvasive DCIS (DCIS-Mi) is distinct from "pure" DCIS. Upfront surgery has a fundamental role in the overall treatment of these breast diseases. The growing number of screen-detected DCIS diagnoses with clinicopathological features of low risk for local recurrence (LR) allows more conservative surgical options, followed by personalised adjuvant radiotherapy plans. Furthermore, studies are underway to evaluate the validity of surgery omission in selected low-risk categories. Nevertheless, the management, the priority of axillary surgical staging, and the prognosis of DCIS-Mi remain the subject of debate, demonstrating how the paucity of data still necessitates adequate studies to provide conclusive guidelines. The current scientific scenario for DCIS and DCIS-Mi surgical approach consists of highly controversial and diversified sources, which this narrative review will delineate and clarify.

Oncoplastic Breast Surgery versus Conservative Mastectomy in the Management of Large Ductal Carcinoma In Situ (DCIS): Surgical, Oncological, and Patient-Reported Outcomes

Oncoplastic level II breast-conserving surgery (OPS2) allows for wider excisions than standard breast-conserving surgery, but the literature on this technique in the treatment of DCIS is scarce. This study compares OPS2 to conservative mastectomy (CM) in patients undergoing surgery for large DCIS. The clinical, radiological, surgical, and post-operative data of 147 patients who underwent either CM or OPS2 for large DCIS between 2007 and 2021 were retrospectively reviewed. The surgical, oncological, and patient-reported outcomes (PRO) were analyzed and compared between the two groups. The surgical outcomes were similar, in terms of margin involvement (p = 0.211), complication rate (p = 0.827), and re-excision rate (p = 1). The rate of additional surgery for cosmetic optimization was significantly lower in the OPS2 group: only 1 (1.8%) patient required surgical adjustments versus 24 (26.4%) patients in the CM group (p < 0.001). The mean hospital stay was lower in the OPS2 group (p < 0.001). The oncological outcomes did not differ between the two groups (p = 0.662). The PRO analysis showed better outcomes in the OPS2 group, which achieved statistical significance in the sexual well-being module (p = 0.015). Skin sensitivity loss was also significantly lower in the OPS2 group (p < 0.001). When feasible, OPS2 should be considered in the treatment of large DCIS, as it is safe and shows high levels of patient satisfaction.

Comparison of Long-Term Oncological Outcomes in Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery for Breast Cancer: A Propensity Score-Matched Analysis

PURPOSE

The oncoplastic breast-conserving surgery (OPS) technique, combined with the principles of oncological safety and plastic surgery, results in complete tumor resection while preserving the natural appearance of the breast. The purpose of this study was to evaluate the long-term oncological results after OPS compared with conventional breast-conserving surgery (BCS) for early breast cancer.

METHODS

The medical records of patients who underwent breast cancer surgery and adjuvant radiation therapy at Seoul National University Hospital between 2011 and 2014 were reviewed. Ipsilateral breast tumor recurrence (IBTR)-free survival rate and recurrence-free survival (RFS) rates were compared between the OPS and BCS groups.

RESULTS

One-to-one propensity score matching was conducted, yielding 371 patients in each group. The mean tumor distance from the nipple was shorter, and the mean retrieved specimen size and pathologic tumor size, including ductal carcinoma in situ, were larger in the OPS group than in the conventional BCS group (p < 0.001). Surgical margin positivity was not significantly different between the two groups (p = 0.777). The surgical technique was not significantly associated with IBTR (OPS versus conventional BCS, 5-year survival rate, 96.9% vs. 98.6%; p = 0.355) and RFS (5-year survival rate, 92.9% vs. 94.5%; p = 0.357) on the log-rank test. Multivariate analysis revealed that OPS versus conventional BCS was not significantly associated with survival outcomes.

CONCLUSION

We observed no significant differences in long-term IBTR and RFS between the OPS and conventional BCS groups in this retrospective analysis. OPS can be an oncologically and surgically safe alternative option for conventional BCS for early breast cancer.

Advances and controversies in management of breast ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. It accounts for 25% of all breast cancers diagnosed, as a result of the expansion of breast cancer screening and is associated with a high survival rate. DCIS is particularly clinically challenging, due to its heterogeneous pathological and biological traits and its management is continually evolving towards more personalized and less aggressive therapies. This article suggests evidence-based guidelines for proper DCIS clinical management, which should be discussed within a multidisciplinary team in order to propose the most suitable approach in clinical practice, taking into account recent scientific studies. Here we include updated multidisciplinary treatment protocols and techniques in accordance with the most recent contributions published on this topic in the peer-reviewed medical literature, and we outline future perspectives.

Female breast cancer in sub-Saharan Africa: A PRISMA-S-compliant systematic review of surgery

BACKGROUND

In sub-Saharan countries (SSAs), the advanced stage at diagnosis and the limited surgical interventions of female breast cancer (FBC) lead to poor outcomes. This study assessed current modalities of FBC surgeries.

METHODS

Six literature databases (Medline, Embase, African Journal Online, Google Scholar, Web of Science, Cochrane Library) were searched, plus a manual search, in 2011-2021. We included primary data studies with any setting and presurgeries or postsurgeries treatments, we excluded non-English language studies, editorials, and grey literature.

RESULTS

The search yielded 21 observational studies (16 retrospective, 3 prospective, and 2 case reports). Of the total 6900 patients, 4121 (60%) patients underwent FBC surgical excision only, and 751/2779 (27%) conservative surgery (BCS) or therapy (BCT). All studies reported similar use of mastectomy (>60%), the FBC surgical excision/reconstruction studies displayed more neoadjuvant chemotherapy (536/2779, 19% vs. 215/4121, 5%), and radiotherapy or adjuvant radiotherapy (1461/2779, 52% vs. 411/3921, 4%). Patients' age, histological classification, staging, and follow-up data were often missing.

CONCLUSIONS

The FBC complexity requires structured management by general and plastic surgeons, radiotherapy specialists, and obstetrician-gynecologists through shared guidelines, protocols, and specific programs of public health. In SSAs, FBC surgical strategies should point at decreasing radical mastectomy and increasing BCS/BCT.

Oncoplastic breast-conserving surgery for women with primary breast cancer

BACKGROUND

Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.

OBJECTIVES

Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.

DATA COLLECTION AND ANALYSIS

Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.

MAIN RESULTS

We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.

AUTHORS' CONCLUSIONS

The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

Oncoplastic Breast-Conserving Surgery for Synchronous Multicentric and Multifocal Tumors: Is It Oncologically Safe? A Retrospective Matched-Cohort Analysis

Background

Oncoplastic surgery is a well-established approach that combines breast-conserving treatment for breast cancer and plastic surgery techniques. Although this approach already has been described for multicentric and multifocal tumors, no long-term oncologic follow-up evaluation and no comparison with patients undergoing mastectomy have been published. This study aimed to evaluate whether oncoplastic surgery is a safe and reliable treatment for managing invasive primary multicentric and multifocal breast cancer.

Methods

The study compared a consecutive series of 100 patients with multicentric or multifocal tumors who had undergone oncoplastic surgery (study group) with 100 patients who had multicentric or multifocal tumors and had undergone mastectomy (control group) during a prolonged period. The end points evaluated were disease-free survival (DFS), overall survival (OS), cumulative incidence of local recurrence (CI-L), regional recurrence (CI-R), and distant recurrence (CI-D), all measured from the date of surgery.

Results

The OS and DFS were similar between the two groups. The incidence of local events was higher in the oncoplastic group, whereas the incidence of regional events was slightly higher in the mastectomy group. These differences were not statistically significant. The cumulative incidence of distant events was similar between the two groups.

Conclusions

To the authors’ knowledge, the current study provides the best available evidence suggesting that the oncoplastic approach is a safe and reliable treatment for managing invasive multifocal and multicentric breast cancers.

Clinical Significance of Oncoplastic Breast-Conserving Surgery and Application of Volume-Displacement Technique

ABSTRACT

Oncoplastic breast-conserving surgery for breast cancer has been continuously developing in recent years, and it has become an important part of breast cancer surgery. Its safety and aesthetics have been widely recognized by domestic and foreign experts. However, due to the complexity and diversity of individuals and diseases, and the need for integrating the thinking of breast surgery and plastic surgery, it is still a challenge for breast surgeons. This review summarizes the pros and cons of its clinical application through a comprehensive discussion of hot issues in oncoplastic breast-conserving surgery and introduces common volume-displacement techniques in the clinic for reference by doctors in daily work.

Efficacy and Safety of Glandular Flap Techniques in Surgical Treatment of Large Ductal Carcinoma in situ

Background

It is well known that full segmentary resection can be performed using oncoplastic surgery (OPS) techniques, and the anatomic resection of the ductal system is possible. Therefore, the efficacy and safety of OPS should be investigated in the treatment of ductal carcinoma in situ (DCIS).

Patients and Methods

Patients who were diagnosed as pure DCIS and underwent surgical treatment and follow-up were retrospectively evaluated. Patients who underwent OPS and conventional breast-conserving surgery (BCS) were included in the study. The number of patients who required an intervention after the surgery and had a relapse during the follow-up period was determined in both groups.

Results

There were 45 patients in the OPS group and 138 patients in the BCS group. The mean tumor size was larger in patients in the OPS group (36 ± 12 mm vs. 24 ± 8 mm, p = 0.02). Six (12.7%) patients were reoperated in the OPS group. Of these, 4 were re-excisions and 2 were mastectomies. In this group, breast conservation was possible in 45 (95.7%) patients. Thirty-nine (27%) patients were reoperated in the BCS group. Of these, 23 were re-excisions, and 16 were mastectomies. In this group, breast conservation was possible in 126 (88.7%) patients (p = 0.02). There was no significant difference between the groups in terms of 5-year cumulative local recurrence rates. While the 5-year local recurrence-free survival rate was 93.3% in the OPS group, it was 90.8% in the BCS group.

Conclusion

This study provided evidence that OPS can be used safely in the surgical treatment of DCIS by reducing re-excision and completion mastectomy rates compared to BCS.

The impact of patient characteristics and lifestyle factors on the risk of an ipsilateral event after a primary DCIS: A systematic review

Objective

The majority of ‘low-risk’ (grade I/II) Ductal Carcinoma In Situ (DCIS) may not progress to invasive breast cancer during a women’s lifetime. Therefore, the safety of active surveillance versus standard surgical treatment for DCIS is prospectively being evaluated in clinical trials. If proven safe and selectively implemented in clinical practice, a significant group of women with low-risk DCIS may forego surgery and radiotherapy in the future. Identification of modifiable and non-modifiable risk factors associated with prognosis after a primary DCIS would also enhance our care of women with low-risk DCIS.

Methods

To identify modifiable and non-modifiable risk factors for subsequent breast events after DCIS, we performed a systematic literature search in PUBMED, EMBASE and Scopus.

Results

Six out of the 3870 articles retrieved were included for final data extraction. These six studies included a total of 4950 patients with primary DCIS and 640 recorded subsequent breast events. There was moderate evidence for an association of a family history of breast cancer, premenopausal status, high BMI, and high breast density with a subsequent breast cancer or further DCIS.

Conclusion

There is a limited number of recent studies published on the impact of modifiable and non-modifiable risk factors on subsequent events after DCIS. The available evidence is insufficient to identify potential targets for risk reduction strategies, reflecting the relatively small numbers and the lack of long-term follow-up in DCIS, a low-event condition.

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Need for risk management strategies for untreated DCIS patients.

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Limited evidence for association between lifestyle factors and prognosis after DCIS.

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Positive family history, premenopausal status, high breast density associated with prognosis.

Oncoplastic Level 2 Mammoplasty for Large DCIS: 5-Year Results

BACKGROUND

Oncoplastic surgery (OPS) allows wider resections with immediate breast reshaping by mammoplasty. This study reviews our experience with level 2 mammoplasties in patients with histology-proven pure ductal carcinoma in situ (DCIS).

METHOD

From a prospectively maintained database of 392 consecutive oncoplastic level 2 mammoplasties, 68 patients presented with pure DCIS. Involved margin rates and locoregional recurrence rates were calculated, with 76 months (0-166 months) median follow-up.

RESULTS

The mean pathological tumor size was 34 mm (median 26 mm, range 2-106 mm). The mean resection weight was 191 g (median 131 g, range 40-1150 g). Margins were clear in 58 cases (85.3%) and involved in 10 cases (14.7%). Margins were involved in 1 out of 54 (1.9%) cases with tumor size under 50 mm and in 9 out of 14 (64.3%) cases with tumor size higher than 50 mm (p < 0.001). On multivariable analysis, only tumor size > 50 mm [odds ratio (OR) 95.400; p < 0.001] was independently associated with involved margins. Seven patients had mastectomy. The overall breast conservation rate was 89.4%, and 100% for tumors less than 5 cm. There were three local recurrences. The 5-year cumulative incidence for local recurrence was 5.5% (0-11.5%).

CONCLUSIONS

OPS is a safe solution for large DCIS up to 50 mm, with an involved margin rate of only 1.9%, and can thus reduce the mastectomy rate in this group. As margin involvement significantly increases for tumors larger than 5 cm, better preoperative localization and/or wider excisions are necessary in this group.